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Diseases Characterized by Vulvovaginal Itching, Burning, Irritation, Odor or Discharge

The majority of women will have a vaginal infection, characterized by discharge, itching, burning, or odor, during their lifetime. With the availability of complementary and alternative therapies and over-the-counter medications for candidiasis, symptomatic women often seek these products before or in addition to an evaluation by a medical provider.

Obtaining a medical history alone has been reported to be insufficient for accurate diagnosis of vaginitis and can lead to inappropriate administration of medication (969). Therefore, a careful history, examination, and laboratory testing to determine the etiology of any vaginal symptoms are warranted. Information regarding sexual behaviors and practices, sex of sex partners, menses, vaginal hygiene practices (e.g., douching), and self-treatment with oral and intravaginal medications or other products should be elicited. The infections most frequently associated with vaginal symptoms are BV (i.e., replacement of the vaginal flora by an overgrowth of anaerobic bacteria including G. vaginalis, Prevotella bivia, A. vaginae, Megasphaera type 1, and numerous other fastidious or uncultivated anaerobes), trichomoniasis, and vulvovaginal candidiasis (VVC). Cervicitis can also cause an abnormal vaginal discharge. Although VVC is usually not sexually transmitted, it is included in this section because it is frequently diagnosed among women who have vaginal symptoms or are being evaluated for an STI.

Multiple diagnostic methods are available for identifying the etiology of vaginal symptoms. Clinical laboratory testing can identify the vaginitis cause in the majority of women and is discussed in detail in the sections of this report dedicated to each condition. In the clinician’s office, the cause of vaginal symptoms can often be determined by pH, a potassium hydroxide (KOH) test, and microscopic examination of a wet mount of fresh samples of vaginal discharge. The pH of the vaginal secretions can be measured by pH paper; an elevated pH (i.e., >4.5) is common with BV or trichomoniasis (although trichomoniasis can also be present with a normal vaginal pH). Because pH testing is not highly specific, vaginal discharge should be further examined microscopically by first diluting one sample in 1 or 2 drops of 0.9% normal saline solution on one slide and a second sample in 10% KOH solution (samples that emit an amine odor immediately upon application of KOH suggest BV or trichomoniasis). Coverslips are then placed on the slides, and they are examined under a microscope at low and high power. The saline-solution specimen might display motile trichomonads or clue cells (i.e., epithelial cells with borders obscured by small anaerobic bacteria), which are characteristic of BV. The KOH specimen typically is used to identify hyphae or blastospores observed with candidiasis. However, absence of trichomonads in saline or fungal elements in KOH samples does not rule out these infections because the sensitivity of microscopy is approximately 50% compared with NAAT (trichomoniasis) or culture (yeast) (670). Presence of WBCs without evidence of trichomonads or yeast might also indicate cervicitis (see Cervicitis).

In settings where pH paper, KOH, and microscopy are unavailable, a broad range of clinical laboratory tests, described in the diagnosis section for each disease, can be used. Presence of objective signs of vulvovaginal inflammation in the absence of vaginal pathogens after laboratory testing indicates the possibility of mechanical, chemical, allergic, or other noninfectious causes of vulvovaginal signs or symptoms. For women with persistent symptoms and no clear etiology, referral to a specialist should be considered.

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